ON THE NATURE OF SNAKE-POISON;

239

discovery of the offending body or bodies. There are, however, other affections of the knee-j )iut which may be mistaken for loose cartilages. These 1 must reserve fur separate

ON THE NATURE OF

few words concerniog the cartilages. In no other single class of cases have the advantage" conferred by Lister’s antiseptic system been more strikingly exemplified than in

consideration, adding operative treatment of

here loose

a

affections which render it necessary to cut into the kneejoint. Formerly the removal of a loose cartilage was often an anxious, and even a hazardouR, operation, whether it It was performed by direct or by subcutaneous inciaion. matters little whose statistics you take—Larrey’a, Volkmann’s, Brthensou’s or Benndorff’8-You will find a considerable proportion of deaths, varying from ab )ut one in eight ca-es to one in five, and in addition to the detths a great mauy failures; and you may be sure of this, that many tatal cases have remainedunrecorded. Even surgeons who in the pre-Listerian epoch were most successful speak in a timid, hesitating tone about the operation, and contemplate the necessity for abandoning it without removing the cartilage. Thus Brodie: "My own experience is in favour of the operation, prjvided that it be done in a cautious and prudent manner. The patient should bj kept in a state of the most perfect quietude for two or three days preceding, and for several days after, the operation. The cartilage having been well fixed, the different parts over it should be slowly and separately divided until it is exposed. The wound of the synovial membrane may be dilated by a probe-pointed biBtonry until it is of sufficient size to allow of the cartilage, being extracted with a tenaculum, and the cut edges of the skin should be instantly replaced in contact with each other, and securel by me-tos of adhesive plaster. There should be no searching for the cartilage in the joint. If it should slip out of the way, the wound should be immediately closed, and the limb should be laid upon a splint until the cut edges are firmly united, the completion of the operation being postponed till a future opportunity."4 Antisepticism has changed all this. Not that there is not the same need of prudence, care, and caution ; not that operations are to b3 lightly undertaken, or that they may not oseasiomDy lead to a fatal issue, even when the most rigid precautions appear to have been adopted, and all the steps of Lister’s process appoar to have been most ftithfully executed. Mr. Barker assures us that the procedure for the removal of loose cartilages "must still be regarded as dangerous, and from time to time with all antiseptic precautions joints are destroyed, as I have seen in one case operated on by a skilful surgeon, and by the most approved methods."" Danger undoubt:dly there is, minimise it as we may, but there are some strong facts on record which point to the conclusion that in operating upon joints, at all events Lister’s method has given us as near an approich to safety and certainty as the imperfection of hum j n agency and human prevision will permit. Hear Professor Volkmann : "The opening of joints seems a most innocent performance. Hips and knees aicut Opfll in order in acase ofluxation to search for the obstacle which opposes itself to reduction, in order to suture the ruptured tissues, and in obscure symptoms to clear up the diagnosis in vieo by meins of autopsy. More than 200 times I alone, without in one instance bad results following, have incised, drained, and washed out diseased knee-joints without exciting suppura’ion."5 These are facts, explain them how you please oa the theory of mere cleanliness and drainage, or any other theory possible or impossible. Ij facts like these could be placed before the judicial mind oi Brodie, what would the verdict be ? Wou’d he consider unreasonable the conviction of Volckmann that the antiseptic method has elevated surgery to th rank of the latest experimental science, and that "the principles of the anti. septic treatment of wounds "-whatever they may ultimately be determined in their essence to be-" will never agaitJ be abandoned as long as the whole of our knowledge is not lost, no matter how our art or the points of attack

may change." 4

---

Op. cit., ch. viii., p. 254.

PRESENTATION.

-

5

Dr.

years has been the medical

THE

LANCET, August 13th,

Gayton,

1881.

who for thirteen

superintendent of the Homerton or Eastern District Hospital for Small-pox, was presented by the staff of that institution, on his appointment to the NorthWestern District Hospital, with a costly drawiog-room clock and appendages, suitably inscribed.

SNAKE-POISON;

ITS EFFECTS ON LIVING CREATURES, AND THE PRESENT ASPECT OF THE TREATMENT OF THE POISONED.

BY SIR JOSEPH FAYRER, K.C.S.I., F.R.S. (Continued from page 196.)

Mode of action of s>zale oisoz.-Iu 18G8-69 I observed that whilst the general character of the eif"et of snakepoison are alike, yet viperine differs from colubrine poison. The poison of D:1j kills without destroying coagulability of the blood, whilst th%t of dilioit (viper) produces complete and permanent fluidity, and ill onnexion with this, the blood of an animal killed by sn,ke-poisoni3 itself poisonous, and if injected into an animal rapidly produces its poisonous etfacts. I have transmitted the venom through a series of three animals with fatal result. Ia 1S33 I described the difference of the action of cobra and daboia venom in the 2 I also pointed out case of two horses bitten by these snakes. the peculiar action of daboia venom in causing early convulsions. In some cases convulsions are m)re marked, and in others death is preceded by a more decided state of lethargy. In the bite of the echis the local symptoms are peculiarly severe.3 Dr. Wall gives a more complete exposition of the varying effects, and shows them to be greater than I supposed. Snake-poison kills by extinguishing in some way (some molecular change) the source of nerve energy. It is also a blood poison and an irritant; if applied to mucoas and serous surfaces it causes inflammation, absorption then takes place, and the symptoms of general poisoning are induced. It causes great local disturoauce as well as blood changes, for if the bitten creature survive long enough the areolar tissue may inflame, suppurate, and slough. If it enters by a large vein life may be destroyed in a few seconds. It was supposed the more active poisons acted by shock through the nervous system ; the rapidity with which a poison can be distributed through the circulation would account for the most rapid death from snake-bite. The chief effect is on the respiratory apparatus, and death occurs by asphyxia, but the whole voluntary muscular system is also affected, and general paralysis resutts, whilst the long continuation of cardiac pulsation after apparent death proves that it is not due to failure of circulation. The action of make-poison is discue at full length in the Proceedings of the Royal Society by Dr. L. Brunton and myself.4 These researches led us tu conclude that the action of the poison is, lirst, on the cerebro-spinal centre?, especially the medulla, indicating general paralysis, especially of respiration ; secondly, in some cases, where the p)ison has been conveyed through a large veiu directly to the heart, by tetanic arrest of cardiac action, probably owing to action on the cardiac ganglia; thirdly, by a combination of these causes ; fourthly, by blood poisoning of a secondary character. The phenomena vary according to the nature of the snake and the individual peculiarities of the creature injured, the chief difference being observed in viperine as contrasted with colubrine poison. The latter is a nerve poison of great deadliness, but as a blood poison it is not of much power. Viperiue poison, on the other hand, is a more potent blood

poison.

Dr. Wall summarises the difference in the action of daboia or cobra (colubrine) poison as follows :"Cobra poison, when introduced slowly into the circulation, produces gradual general paralysis, but at the same time shows a preference for certain nerve-centres, paralysis of the tongue, lips, and larynx being very marked symptoms, and respiration is very quickly extinguished after the paralysis shows itself. Death is often atteuded with convulsions, which are clearly due to carbonic acid poisoning. Introduced with a fair amount of rapidity, these symptoms are rapidly developed, the paralysis being preceded by gentle stimulation, which causes slight muscular twitchings. Injected in a large quantity into the circulation the stimulation is so violent as to cause general convulsions, of which, however, the respiratory muscles have the chief share and which are

(viperine)

1 3

Thanatophidia, p. 4. Ibid., p. 631.

24 Ibid., p. 79. At p. 72, 73, op. cit.

1873, 1874, 1875, and

1878.

240 of time will be obtained by dividing the period in spaces of hour each, and determining what percentage of deaths in each :-

immediately followed by paralysis and death. Daboia poison though not injected directly into the circulation, causes thl most violent convulsions, which are in no way necessaril followed by paralysis and death, but may be for the time com pletely recovered from. They do no depend on carbonic aci( poisoning. The paralysis that succeeds is general, and last; a very considerable time before respiration is extinguished There is no evidence of the tongue, lips, and larynx bein especially paralysed, they probably only suffer in the sam( degree as other parts. Cobra poison very quickly destroYI the respiratory functions (after slight acceleration the respi ration becomes slower, and the excur,ms is lessened). Daboi poison at first quickens the respiration very much more thar cobra poison does, and the lessening of the excursus anc

one occurs

the slowing of the breathing do not occur so soon. Thf respiration generally in daboia poisoning has a peculiarly irregular character. This function certainly exists longei

under the influence of daboia poison than under that oj poison. The enect of cobra poison on the pupil is sc slight as to be a matter of doubt; daboia poison nearly always causes wide dilatation in the earliei stages of the poisoning. Salivation is a constant symptom of cobra poisoning ; it is exceedingly rare in daboia, poisoning. The etfect of cobra poison in the blood is not very great, sanious discharges are rare, albuminuria has not been seen, and recovery is striking and complete (when it takes place). In daboia poisoning, on the other hand, sanious discharges are the rule, albuminuria is usual should the victim live any time, and after the nerve symptoms have passed away the subject has to go through a period of blood poisoning, little, if at all, less dangerous than the primary symptoms; we have in addition the greater local misc uef caused by daboia poisoning, and the greater power it ba,3 of destroying the coagulation of the blood. The physiological properties of daboia poison undergo great change by is being heated to 100° C. in solution, lusing the power of producing primary convulsions, whereas cobra poison remains unaltered. Daboia poison kilis birds at once in convulsions; whereas with cobra poison, unless the poison has been directly injected into the circulation, death occurs only after paralysis. Lastly, amphibia recover from an amount of daboia poison that would be necessarily fatal in the case of cobra poison." Without unreservedly accepting Dr. Wall’s conclusions, I regard them as an able summary of the action of different kinds of snake-poison, and which confirms the deadly nature of Indian, as compared with European, sriake-poisou. Symptoms and effects of the poison.-The local effects of the poison are partial paralysis of the bitten part, pain, infiltration, swelling, inflammation, and ecchymosis round the spot where the poison has been introduced, and sometimes in other and distant parts, and if the animal survivefor some hours haemorrhage, infiltration, necrosis, and decomposition of the tissues. The general symptoms are depression, faintness, cold sweats, nausea, vomiting, exhaustion, lethargy, unconsciousness. Dogs vomit, and are profusely salivated ; they present an appearance as of the hair "staring." As the poisoning proceeds paralysis appears in the limbs, the hinder ones first, generally seeming to creep over the whole body, involving the tongue and the muscles of deglutition, with loss of the coordinating power of the muscles of locomotion. Albuminuria (especially in viperine poisoning), hsemorrhagic discharges, relaxation of sphincters, exhaustion, lethargy, and convulsions precede death. In fowls the appearance is that of great drowsiness ; the head falls forward, rests on the point of the beak, and gradually the bird, no longer able to support itself, rolls over on its side. There are frequent startings, as if of sudden awakening from the drowsy state, then convulsions and death. In cases where the quantity of poison injected is large, and it is at the same time very active (as in cobra), the bitten animal small and weak, or if it have entered a vein, death is almost instantaneous, as from shock. In such cases the cardiac ganglia are probably paralysed, at all events the heart suddenly ceases to beat. The effects of snake-poison on man are much of the same character, and may be studied in the details of sixty-five cases recorded in the "’rhanatophidia," which also give an idea of the duration of life. Dr. Wall has summarised this as follows : " The average length of time of the sixty-five cases is fifteen to seventeen houra, but the average is raised by the exceptionally long duration of a few cases of viperine poisoning, so that a better estimate of the probable duration

The most fatal

periods appear to be between two and three and more than 25 per cent. of the total deaths take between one and three hours after the infliction of the bite." It appears also from the above report, in which in fifty-four cases the exact spot is described, that 94 54 per cent. were wounded in the extremities :—

cobra

hours,

place

This is

a matter of some interest, as the hope of success lies preventing access to the circulation, and in the facility of removing the part injured, and with it the inoculated venom. The greater proportion of deaths recorded result from the direct effects of the poison. Chronic cases, in which death or recovery resulted after protracted periods, are less frequently referred to. Snake poisoning in this country is of the viperine character, and though, happily, the activity of our viper is feeble compared with that of the tropical viperidse, and, except in the case of very weak or young creatures, its immediate effects as a nerve poison are feeble, yet the effect on the blood, and locally on the tissues, may be productive of severe and even dangerous symptoms. I am indebted to the Director-General of the Army Medical Department for the following case, which will appear in detail in the next Army Medical Department annual report: "Case of Lieut.-Colonel N. M-, aged forty-five years. " Service twenty-five years.

in

"BY SURGEON-MAJOR HARVIE SCOTT, M.B. ! "On the afternoon of Friday, the 21st September, 1883, Colonel M-, in company with an officer of the regiment, rode out for the purpose of shooting in that part of Zululand near the Lower Tugela river. When the ground was reached where he was going to shoot he dismounted and walked through rather long grass. In a few minutes he felt a sharp pain in the upper part of his left leg, and after the lapse of a few seconds suddenly became sensible of extreme shock to his system, and at once felt certain that a snake had bitten him; he called out to his companion, who at once rode up to him and volunteered to cut and suck the affected part, but the colonel would not permit him to do so, and as he was not more than ten minutes’ ride from camp he rode back as fast as his strength would permit. On his arrival in camp I at once saw him, and his condition was as follows :-Locally, pain, ecchymosis, swelling and partial paralysis of bitten part. Generally so great was the exhaustion that he has nearly fallen off his horse ; forehead and hands were bathed in a cold clammy perspiration ; extremities cold and pale ; sinking sensation in epigastrium, great nervous depression, with a sense of

if

impending death ; respiration hurried. Almost immediately after arrival in camp bilious vomiting set in, loss of coordinating power, numbness of hands, forearms, feet, and lips, with dragging sensation of muscles of the face ; intense pain in neck ; cough of a troublesome nature; expectoration of tenacious viscid mucus, which was with difficulty

,

241 removed from the mouth. 120 per

Pulse at first weak and

minute, running up afterwards to

150 per

rapid,

I

minute,

ON THE

I

(jumping PHYSIOLOGY OF THE CARBOHYDRATES IN thready; up suddenly in bed) and anxiety becoming most distressing ; THE ANIMAL SYSTEM. vomiting ceased at 9 P. M., up to which time he appeared on the BY F. W. PAVY, M.D., F.R.S. whole to be progressing favourably, but after that most grave so became weak rapidly sight symptoms developed-viz., (Continued from p. 198.) that he could hardly distinguish anything in his tent ; the eyelids drooped; speech thick and nasal; paralysis of tongue M allose and Grape Sityar. and soft palate; dysphagia; clonic convulsions of upper extremities and muscles of chest; dyspnoea,; stertorous TEN cub. centims. of the solution of grape sugar, equivalent breathing with low muttering. Consciousness remained up to ’207 grm. glucose, were mixed with 50 cub. centims. of the to 12.45 A.M., when he last spoke to me, and asked my solution of maltose having a power equivalent to opinion as to his pulse and chances of recovery ; he then ’165 grm. glucose before boilingreducing with sulphuric acid and ’426 lapsed into a semi-comatose condition, and died a little added to the and water volume to 150 cub. centims. bring before two o’clock on the morning of Sept. 22nd, exactly after, ten hours subsequent to the fatal bite.—Treatment: Tight This was divided into three equal parts, which were dealt compression was made above the seat of injury between the with as shown below, the results obtained being mentioned. bite and the heart; wound enlarged, and an attempt made to remove all the blood and poison from it. Nitrate of silver and ammonia were applied freely to the surface of the restlessness

and becoming very weak and

wound. Ammonia and diffusible stimulants were administered by mouth. To relieve the distressing vomiting sinapisms were applied to the region of the stomach, and brandy with soda-water given; the restlessness was combated with hypodermic injections of morphia (half grain for a dose), the morphia gave great relief, which, however, was only transitory. Hot-water bottles were applied to the feet, and stimulants were given with an unsparing hand, but were not always retained. Ammonia was also injected subcutaneously. Post-mortem examination, nine hours after death: Body well nourished. Cadaveric rigidity well marked. Hypostatic congestion. Great discolouration of scrotum and finger nails. Situation of bite on left leg at upper and inner side of calf, about three inches below internal condyle of femur, and immediately over internal saphena vein; appearance that of a small piu puncture; lower part of leg rather swollen. On removing the skin from the region of the wound there was found great serosanguineous extravasation into the surrounding tissues, and the muscles were softand infiltrated with the internal saphena vein was punctured. The venous system on the left side much congested. The glands in left groin, in long axis of limb, enormously enlarged and congested. Glands in right groin normal. Pericardium normal. Heart, right cavities of, full of fluid blood; left cavities empty ; valves healthy; no clots. Lungs normal. Liver congested and slightly enlarged. Gall-bladder fully distended. Spleen somewhat enlarged, otherwise normal. Stomach slightly congested; rugse well marked; contents, a small quantity of glairy mucus. Kidneys normal. Omentum contained much adipose tissue. Intestines normal. Bladder normal, contained a small quantity of urine. Brain somewhat congested, otherwise normal. Blood in a fluid state.-Remarks: .The snake which inflicted the fatal wound was not seen; in all probability Colonel M—— trod on one asleep, which then struck at him. The systemic shock was at once apparent after receipt of the injury, which is accounted for by the puncture of the internal saphena vein, and the introduction of the poison direct into the general circulation. The clothing traversed by the fang of the snake was, first, cloth gaiter ; second, khakee riding breeches ; third, drawers of light material. From the high situation of the puncture, the opinion of competent judges was that the snake which inflicted the wound was ablack mambi’ [one of the viper -

blood ;

species not determined].

(To

Fort

be

Thus, observation shows that there is no difficulty in distinguishing the carbohydrates in combinations under the conditions required to be unravelled. Now let us see how the results stand when the mode of investigation described is put into practice. Expera-jnent.-Some cane sugar, scraping from the intestine of a dog, and about 150 cub. centims. of water were placed in a wide-mouthed bottle and exposed to a temperature of 120° F. Twenty cub. centims. were removed at the subjoined periods, made up to 150 cub. centims. with water, divided into three parts of 50 cub. centims. each, and examined-one part by titration at once, and the other two parts after boiling for seven minutes with citric acid (2 per cent. strength) and sulphuric acid respectively. The figures give the cupric-oxide reducing power expressed as glucose, calculated for what it would be under the different circumstances in the whole 150 cub. centims. (to which the 20 cub. centims. were diluted) of liquid each time subjected to analysis. An analysis of the intestinal product itself that was employed gave no reducing action before or after treat. ment with sulphuric acid.

continued.)

Curtis, Etshowe, Zululand, Nov. 10th, 1883."

MANCHESTER MEDICO-ETHICAL ASSOCIATION.—The annual meeting of this Association was held on January 31st. The reports of the committee showed the continued prosperity with a steady increase of members and funds. The following gentlemen were elected office-bearers and members of committee for the year 1884 :-President : Dr. Lloyd Roberts. Vice-Presidents : Mr. G. Bowriag, Dr. Cullingworth, Mr. F. H. Walmsley, Dr. S. Woodcock. Treasurer: Dr. Joseph Stone. Secretaries : Dr. Wahltuch, Mr. J. Broadbmt. Committee : Drs. H. Ashby, W. H. Barlow, S. Buckley, F. H. Collins, A. M. Edge ; Messrs. J. Foster, E. Meacham, J. Westmorland; Drs. C. E. Glascott, W. J. Mallett, F. M. Pierce, W. Walter.

Let us now examine these figures. At the end of five minutes the 20 cub. centims. of liquid taken from the bottle contained a product derived from the transformation of the cane sugar originally present, possessing a cupric-oxide reducing power equivalent to ’036 grm. of glucose. After boiling with citric acid the contents of the 20 cub. centims. possessed a reducing power equivalent to ’087 grm. glucose,